Ronald Compson

24 Jan 2018 · Coroner Zafar Siddique · Black Country

The coroner's concerns

1. failure to contact a Doctor
“failure to contact a Doctor and it isn't clear if this was a system failure through the "nerve centre" system designed to inform the on call Doctor”
2. vomiting incidents and poor record keeping
“two separate incidents of vomiting and poor record keeping of when these occurred”
3. poor communication to family about initial fall
“poor communication to the family about the initial fall”

Stated action · target dates for completion of those actions

“The enclosed action plan confirms the actions taken subsequent to the investigation and target dates for completion of those actions.”